MELISSA E. RINCK, D.D.S. & JUDY CHAU, D.D.S.
750 LAS GALLINAS AVE., #215
SAN RAFAEL, CA 94903
(415) 479-4977
Smile Analysis
Name:
Date:
When you see your smile in the mirror, do you like the way your teeth look?
Yes
No
If you had a magic wand, is there something about your smile you would change?
Yes
No
Please describe how you would like your teeth to look.
Do you have any black mercury fillings that show, or concern you, that you would like replaced?
Yes
No
Would you like to easily whiten your teeth?
Yes
No
Do you have any old crowns or caps that don't match your natural teeth or you are unhappy about?
Yes
No
Do you clench or grind your teeth?
Yes
No
Are you interested in information about halitosis or bad breath?
Yes
No
Dental Information
Do your gums bleed when your brush?
Yes
No
Are your teeth sensitive to heat or cold?
Yes
No
Are your teeth sensitive to pressure?
Yes
No
Are your teeth sensitive to sweets?
Yes
No
Do you have any fear of dental work?
Yes
No
Date of last dental visit
What was done at the time?
Former Dentist's Name
City
How would you describe your current dental problem?
How do you feel about the appearance of your teeth?
Patient Validation:
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